F. Babre

Intravenous peripherally-inserted central catheters for antibiotic therapy in children with cystic fibrosis ☆

BACKGROUND We aimed to evaluate the use of central catheters introduced by a peripheral vein (PICC) in children with CF. METHODS A descriptive study in patients in whom a PICC (Beckton Dickinson) was inserted. RESULTS 24 children aged (median (range) 10.2 years (0.3-17.3) undergoing 44 procedures were included. PICC was successfully inserted in 93.2% (41/44) of cases. Total procedure duration was (median (range)) 32.5 (10-105) minutes. The operators encountered few difficulties, median (range) 2 (1-10) (1 (absence) to 10 (maximal)); median (range) 1 (1 to 5) attempt per child). No major side effects or infections were observed. PICC obstruction in 5 (12%) cases was successfully unblocked in 4 cases (urokinase). The catheter was functional throughout the antibiotic course in 40/41 cases. A final Doppler scan (30 cases) showed total permeability of the central veins in all cases. Satisfaction index of the operators and the patients were high: median (range) 9.5 (1-10) and 8.0 (6-10) (scale: 1 (worse) to 10 (best)), respectively. CONCLUSION PICCs are simple to use, and may be safely inserted in the ward. Such catheters are well tolerated, may increase the well-being of children with CF and prove an effective means by which to deliver IV therapy in this population.

Minimal effective dose of indomethacin for the treatment of patent ductus arteriosus in preterm infants.

The aim of this study was to determine if it was possible to decrease the number of boluses of indomethacin for the treatment of patent ductus arteriosus. This retrospective study included 46 preterm neonates (<34 weeks’ GA) who had had an ultrasound diagnosis predictive of subsequent symptomatic patent ductus arteriosus. All patients had received a daily intravenous doses of indomethacin, 0.1 mg/kg. Mean age at initiation of treatment was 4.5 ± 3.1 days. Patency of the ductus arteriosus was controlled echocardiographically each day and treatment was discontinued as soon as the ductus arteriosus was closed. The initial success rate was 84.7%, of which 6.5% reopened. The mean cumulative dose of indomethacin was 0.35 mg/kg. There was no correlation between gestational age or birth weight and total cumulative dose. Overall tolerance was satisfactory with only one case of transient acute renal failure. A weak correlation between the cumulative dose of indomethacin and natremia (r = –0.43) or weight gain (r = 0.35) was noted, and none with serum creatinine or blood urea nitrogen levels. We confirm that lower indomethacin treatment of patent ductus arteriosus in premature neonates are as effective as standard protocols.

Frequency and risk factors for malnutrition in children undergoing general anaesthesia in a French university hospital: A cross-sectional observational study

BACKGROUND Malnutrition is often underdiagnosed in hospitalised children, although it is associated with postoperative complications, longer hospital lengths of stay and increased healthcare-related costs. OBJECTIVE We aimed to estimate the frequency of, and identify factors associated with, malnutrition in children undergoing anaesthesia. DESIGN Cross-sectional observational study. SETTING Paediatric anaesthesia department at the University Childrens Hospital, Bordeaux, France. PARTICIPANTS A total of 985 patients aged less than 18 years. MAIN OUTCOME MEASURES Anthropometric measurements, American Society of Anesthesiologists physical status classification score and the Pediatric Nutritional Risk Score (PNRS) recorded at the pre-anaesthesia evaluation. RESULTS When assessed as a Waterlow index less than 80%, malnutrition was present in 7.6% children. This increased to 8.1% of children assessed by clinical signs and to 11% of children when defined by a BMI less than the third percentile. In a univariate analysis, children with a BMI less than the third percentile were more often born prematurely (22.4 vs 10.4%; P = 0.0008), were small for gestational age at birth (18.4 vs 4.5%; P < 0.0001), were admitted from the emergency department (12.0 vs 5.6%; P = 0.02), had a high American Society of Anesthesiologists score (P < 0.0001), or had a high Pediatric Nutritional Risk Score (P < 0.0001). Presence (P = 0.01) and type (P = 0.002) of chronic disease were also associated with malnutrition. In the multivariate analysis, a premature birth, a lower birth weight and a higher Pediatric Nutritional Risk Score were significantly associated with a higher odds of malnutrition when defined by BMI. CONCLUSION All children should be screened routinely for malnutrition or the risk of malnutrition at the pre-anaesthesia visit, allowing a programme of preoperative and/or postoperative nutritional support to be initiated. We suggest that as well as weight and height, BMI and a pediatric nutritional risk score such as PNRS should be recorded routinely at the pre-anaesthesia visit.

[Surgery for soft-tissue sarcomas of the limbs and trunk wall].

Soft-tissue sarcoma of the limbs or the trunk wall determine a heterogeneous group of tumours that tends to receive a more individualized approach. The surgeon in charge with soft-tissue sarcoma has to be familiar with these tumours in order to deliver an adequate treatment. Most important is the initial diagnostic procedure, comprising imaging with MRI, a core needle biopsy, and in France, referral to a centre of expertise within the clinical network NETSARC. Prior to surgery, a multidisciplinary conference determines its moment and the extent of surgical resection within the frame of a multidisciplinary approach, and also plans reconstructive surgery, when needed. A standardized operative report summarizes items necessary to describe the resection quality (i.e. tumour seen, tumour infiltrated?). In multidisciplinary staff meetings, they are compared to margins measured by the pathologist on the operative specimen. Hence, resection quality is determined collegially and defined by resection type R (R0, R1, R2) as a qualitative result. The quality of resection directly determines the 5-year risk of local recurrence, estimated between 10 and 20% in specialized centres, with the objective to attain 10%. Early rehabilitation favours better functional outcome. The surgeons experience with soft-tissue sarcoma, as part of a multidisciplinary treatment, is key in achieving the best adequacy between oncological resection and favourable functional outcome. In France, a specific university course for soft-tissue sarcoma will be set-up.

66 L’hypomagnésémie : une cause possible de convulsion néonatale

Les troubles hydro-electrolytiques et glycemiques sont recherches systematiquement en cas de crise convulsive neonatale, l’hypomagnesemie plus rarement. L. est une jumelle nee prematurement a 27 SA (HELLP syndrome), atteinte de dysplasie broncho-pulmonaire (traitement par diuretiques et corticoides), recevant une nutrition parenterale prolongee du fait d’une intolerance alimentaire. A 38 SA d’âge corrige elle presente des crises convulsives tonico-cloniques subintrantes avec apnees. Biologiquement, il existe une hypokaliemie, une hypophosphoremie et une alcalose metabolique moderees. Glycemie, calcemie et examen cytobacteriologique du liquide cephalorachidien sont normaux. L’echographie transfontanellaire est stable (hemorragie de grade 1). L’electroencephalogramme met en evidence des paroxysmes alternant sur les deux hemispheres. Devant la persistance des crises malgre un traitement anti-convulsivant, L. est transferee dans le service de reanimation pour assistance respiratoire. La magnesemie demandee en seconde intention est effondree (0,13 mmol/l). La correction progressive de l’hypomagnesemie permet un arret des convulsions sans recidive. L’hypomagnesemie est responsable d’une symptomatologie neuromusculaire et/ou cardiovasculaire riche. Elle est favorisee par la prematurite et liee a un defaut d’apport (nutrition parenterale prolongee, troubles de l’absorption) et/ou des pertes excessives digestives ou renales (diuretiques, aminosides). La teneur en magnesium des laits maternels ou artificiels est suffisante alors que certaines solutions pour nutrition parenterale n’en contiennent que de faibles quantites. L’hypomagnesemie est une cause de convulsion neonatale a rechercher. Une surveillance des apports en magnesium des nouveau-nes recevant une alimentation parenterale est necessaire, surtout si celle-ci est exclusive et en cas de traitement par diuretique ou aminoside.